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J, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,QE'FIR USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 /d'-7 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. /1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 230 1/2 E. Lodi Avenue - Well 1 CENSUS TRACT 32850 <br /> Owner's Name City of Lodi Phone 368-0641 <br /> Address 221 W. Pine St. City Lodi <br /> Contractor's Name ---. License # Phone ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_ x <br /> PUMP INSTALLATION / / PUMP REPAIR/ / - PUMP REPLACEMENT <br /> Other /X/ Lower pump <br /> DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES 14' PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT -- OTHER __ ■ <br /> PROPERTY LINEIQ'PRIVATE DOMESTIC WELL ' --- PUBLIC DOMESTIC WELL --- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation C1�y <br /> Domestic/private Drilled Dia. of Well Casing Q <br /> __X _ Domestic/public Driven Gauge of Casing \ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done t7 <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth C <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT the well and notify them before putting the well in use. The above <br /> informs ion is true tA thefpest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIORTO UTIFIItkL INSPECTION. <br /> SIGNED TITLE Public Works Director <br /> bRAW P1 T PLAN ON REVERSE SIDE) ',. 1� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE _ <br /> APPLICATION ACCEPTED BY i DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 <br /> 3/7 2M <br /> r <br />